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Question 1

What a painful 3rd nerve palsy may be suggestive of?

Answer 1

Posterior communicating artery aneurysm

e.g. 3rd nerve palsy + headache

Question 2

What muscles are affected in 3rd nerve palsy?

Answer 2

• Lateral rectus* + superior oblique -> unopposed action = eye down and out
• Levator palpebrae* = ptosis

Question 3

What may be the cause of:

3rd nerve palsy (ptosis + eye down and out) + pupil dilation

Answer 3

microvascular cause (e.g. compression/aneurysm)

also look for: neck stiffness, vomiting and headache) -> an aneurysm compressing on posterior communicating a.

Question 4

Where would be the lesion localised if:

3 rd nerve palsy (ptosis) + upgaze

Answer 4

Midbrain

Question 5

Where would be the lesion localised if:

ptosis + ataxia + hemiparesis

Answer 5

midbrain

Question 6

Location of the lesion if:

facial pain, numbness (forehead) + 3rd nerve palsy + decreased corneal reflex

Answer 6

Cavernous sinus #

Question 7

What’s Weber’s syndrome?

Answer 7

Weber’s syndrome:

ipsilateral third nerve palsy with contralateral hemiplegia -caused by midbrain strokes

Question 8

Autonomic dysreflexia

• symptoms and signs
• at which level of spinal cord injury does it occur?

Answer 8

Autonomic dysreflexia

Spinal cord injury: above T6 level

Presentation: a combination of severe hypertension, flushing and sweating without a response in heart rate in the context of spinal cord injury -> autonomic dysreflexia

Question 9

What is the cause of autonomic dysreflexia in a person with spinal cord injury and when (example) a catheter is placed?

Answer 9

Cause: discontinuity between the nociceptors on the viscera and the brain stem autonomic centres due to the cord injury

• all the pain receptors on smooth muscle on the abdominal and some pelvic viscera are carried by the sympathetics
• the specific nerve which extends to the pelvis is the greater splanchnic nerve (which has its lowest innervation at T6 and so this is the lowest level at which autonomic dysreflexia can still occur)

Question 10

Patient with unilateral deafness or tinnitus

What condition do we need to consider?

Answer 10

Acoustic neuroma

*also may present with facial palsy

* requires urgent referral for ENT surgery

Question 11

What is the nature of symptoms in Presbycusis?

Answer 11

Bilateral

Question 12

When otitis media may be excluded - examination wise

Answer 12

The normal ear examination and Rinne’s/Weber’s tests suggesting a sensorineural deafness

Question 13

Typical history of vestibular schwannoma (acoustic neuroma)

Answer 13

The classical history of vestibular schwannoma includes a combination of: vertigo, hearing loss, tinnitus and an absent corneal reflex.

Features can be predicted by the affected cranial nerves:

• cranial nerve VIII: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
• cranial nerve V: absent corneal reflex
• cranial nerve VII: facial palsy

Question 14

What are (5) sinister signs of headache?

*what to do?

Answer 14

Sinister signs of headache

• Vomiting more than once with no other cause
• New neurological deficit (motor or sensory)
• Reduction in conscious level (GCS)
• Valsalva (associated with coughing or sneezing) or positional headaches
• Progressive headache with a fever

Do an urgent CT head scan

Question 15

CSF flow

Answer 15

Question 16

Essential tremor

• what’s the cause
• management

Answer 16

Essential tremor

Cause: an idiopathic, mixture of genetic and environmental factors (no specific gene has been identified yet)

Management:

(depend on Rx severity - not all require treatment)

• lifestyle: cut down on caffeine, avoid stress, good sleep
• Meds:

1st line -> B blockers -> propranolol

2nd anti-epileptics: topiramate, gabapentin or other alternatives

3rd line -> mirtazapine, clonazepam

• if meds do not help: botulinum toxin, deep brain stimulation and occupational therapy input

Question 17

Hypsarrhythmia on EEG is suggestive of which type of seizure?

Answer 17

Hypsarrhythmia

• seen in infantile spasms or West’s syndrome
• It has a poor prognosis and regression in skills often occurs
• Hypsarrhytmia - is defined as continuous, high-amplitude, arrhythmic, asynchronous delta activities with interspersed independent, multiple spikes

Question 19

Thrombolysis

• (2) criteria
• Drug used

Answer 19

Thrombolysis should only be given if:

• it is administered within 4.5 hours of onset of stroke symptoms (unless as part of a clinical trial)
• haemorrhage has been definitively excluded (i.e. Imaging has been performed)

Alteplase is currently recommended by NICE.